Step-up Yellow Zone Inhaled Corticosteroids to Prevent Exacerbations

Phase 3

Completed

Brief Summary: The objective of this study is to determine whether, in children receiving low-dose inhaled corticosteroids (ICS), quintupling the dose of inhaled corticosteroids at the onset of symptoms previously associated with upper respiratory illnesses and subsequent asthma exacerbations reduces the rate of severe asthma exacerbations treated with oral corticosteroids.

Detailed Description: The study design is a double-blind, parallel-group trial, including a total of 250 participants, ages 5-11 years, with a diagnosis of asthma and a history of at least 1 asthma exacerbation treated with oral corticosteroids in the prior year. All participants will be treated for 48 weeks with open-label fluticasone 44 mcg 2 puffs twice daily. During the 48-week treatment period, participants will receive randomized blinded therapy for 7 days each time they enter the "yellow zone" (at the onset of symptoms previously associated with upper respiratory illnesses and subsequent asthma exacerbations). Yellow zone therapy will be fluticasone 44 or 220 mcg 2 puffs twice daily.

Recruitment & Eligibility

Inclusion Criteria

Physician-diagnosed asthma
At least 1 exacerbation treated with systemic (oral or injectable) corticosteroids in the past 12 months
Able to perform reproducible spirometry
Current treatment with step 2 controller therapy [low-dose ICS, leukotriene receptor antagonist (LTRA)] OR current treatment with step 3 controller therapy [low-dose ICS + long-acting beta agonist (LABA), low-dose ICS + LTRA, or medium dose ICS] with a childhood Asthma Control Test (c-ACT) score of >19, no more than 2 prednisone treated exacerbations in the past 6 months, prebronchodilator Forced Expiratory Volume at 1 second (FEV1) ≥ 80% predicted and willing to step down therapy OR controller naïve and qualifying for step 2 controller therapy [asthma symptoms or short acting beta agonist (SABA) use > 2 days per week or night-time awakenings due to asthma > 2 nights per month]
Prebronchodilator FEV1 ≥ 60% predicted
Ability and willingness to provide informed assent
For females of childbearing potential: not pregnant, non-lactating, and agree to practice an adequate birth control method.
History of clinical varicella or varicella vaccine

Exclusion Criteria

Systemic (oral or injectable) corticosteroids within previous 2-week period
Current or recent (previous 2-weeks) use of medications known to significantly interact with corticosteroid disposition, including but not limited to carbamazepine, erythromycin, phenobarbital, phenytoin, rifampin, and ketoconazole
Presence of chronic or active lung disease other than asthma
Significant medical illness other than asthma, including thyroid disease, diabetes mellitus, Cushing's disease, Addison's disease, hepatic disease, or concurrent medical problems that could require oral corticosteroids during the study
A history of cataracts, glaucoma, or any other medical disorder associated with an adverse effect to corticosteroids
History of a life-threatening asthma exacerbation requiring intubation, mechanical ventilation, or resulting in a hypoxic seizure
More than 5 prednisone treated exacerbations in the past 12 months
More than 1 hospitalizations lasting >24 hours for asthma in the past 12 months
History of adverse reactions to ICS preparations or any of their ingredients
Receiving hyposensitization therapy other than an established maintenance regimen (On maintenance regimen for ≥ 3 months)
History of premature birth before 35 weeks gestation

Arm && Interventions

Group	Intervention	Description
Fluticasone 44 mcg	Fluticasone 44 mcg	Fluticasone 44 mcg 2 puffs twice daily for 7 days initiated at the onset of "yellow zone" symptoms.
Fluticasone 220 mcg	Fluticasone 220 mcg	Fluticasone 220 mcg 2 puffs twice daily for 7 days initiated at the onset of "yellow zone" symptoms.

Primary Outcome Measures

Name	Time	Method
Asthma Exacerbations	end of 48 week treatment period	The primary outcome is the rate of severe asthma exacerbations treated with oral corticosteroids during the 48 week treatment period.

Secondary Outcome Measures

Name	Time	Method
Number of Participants Hospitalized for Asthma	end of 48 week treatment period	Number of participants hospitalized for asthma during the 48 week treatment period.
Yellow Zone Asthma Symptoms	end of 48 week treatment period	Study participants completed a daily symptom diary. They scored the following diary elements on a scale from 0-3 (none-severe): Cough, Wheeze, Trouble Breathing, Interference With Activities. A combined score was calculated as the sum of the 4 elements and ranged from 0 to 12. The study intervention was based on yellow-zones as noted in the Study Description. This outcome was based on diary data including 21 days, beginning 7 days prior to the onset of the yellow-zone intervention and ending 14 days after the onset of the intervention. The total symptom burden outcome was defined as the sum of the combined score on each diary day and ranged from 0 to 252 (max combined score of 12 per day multiplied by 21 days). A score of zero would indicate no symptoms over the entire 21 days. A score of 252 would indicate severe cough, wheeze, shortness of breath, and interference with activities on all of the 21 days.
Yellow Zone Albuterol Use	end of 48 week treatment period	Use of albuterol rescue medication during 7-day yellow zone episodes.
Unscheduled Emergency Department (ED) or Urgent Care Visits for Asthma	end of 48 week treatment period	Rate of emergency department (ED) or urgent care visits for asthma during the 48 week treatment period.

Locations (17): University of Illinois at Chicago
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Chicago, Illinois, United States
National Jewish Health
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Denver, Colorado, United States
University of Wisconsin
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Madison, Wisconsin, United States
University of Arizona College of Medicine
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Tucson, Arizona, United States
Nemours Children's Clinic
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Orlando, Florida, United States
Emory University
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Atlanta, Georgia, United States
Children's Hospital Boston
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Boston, Massachusetts, United States
St. Louis Children's Hospital
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Saint Louis, Missouri, United States
Wake Forest University Health Sciences
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Winston-Salem, North Carolina, United States
Children's Hospital & Research Center Oakland
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Oakland, California, United States
UCSF Benioff Children's Hospital
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San Francisco, California, United States
Rush University Medical Center/Stroger Hospital
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Chicago, Illinois, United States
Washington University
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Saint Louis, Missouri, United States
Ann and Robert H. Lurie Children's Hospital
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Chicago, Illinois, United States
Children's Hospital of Pittsburgh of UPMC
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Pittsburgh, Pennsylvania, United States
Rainbow Babies and Children's Hospital, Case Western Reserve University
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Cleveland, Ohio, United States
Allegheny General Hospital
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Pittsburgh, Pennsylvania, United States